EXECUTIVE SUMMARY

People with diabetes are twice as likely to experience symptoms of depression as people without the disease. New research revealed integrated treatment is effective when it improves medical and mental healthcare of patients with diabetes.

  • Investigators found complementary and integrative health approaches can result in better patient health and satisfaction.
  • Another study revealed people with type 2 diabetes benefit from exercise and/or cognitive behavioral therapy.
  • Patients achieve better glycemic control when their medical and mental health are integrated.

New research revealed the health of people with diabetes and other chronic illnesses improves when healthcare providers integrate medical and mental services, including better glycemic control.1,2

Diabetes affects about one in 10 Americans. People with diabetes are twice as likely to experience depressive symptoms as those without diabetes. One in four people with diabetes experience symptoms of depression, and about 11% meet criteria for diagnosis of a major depressive disorder.3

Investigators found patients with diabetes saw better physical health outcomes when they received integrated diabetes and depression care.1

“This is a study where we were interested in trying to understand whether better integration of diabetes and depression care was associated with better glycemic control,” says Neda Laiteerapong, MD, MS, associate professor of medicine and associate director of the Center for Chronic Disease Research and Policy at the University of Chicago.

Laiteerapong and colleagues focused on a patient population at federally qualified health centers (FQHCs). They sent surveys to behavioral health directors, FQHC leaders, and primary care providers who worked with FQHCs. The surveys focused on defining features of behavioral health and primary care integration among patients with diabetes.1 FQHCs provide healthcare to underserved populations, and some include integrative behavioral health services, Laiteerapong says.

The study began in 2016, the same year the American Diabetes Association (ADA) published a position statement encouraging the integration of psychosocial care and medical care for all people with diabetes.1

Other research supports integrated mental and medical health services. For instance, a study from the Veterans Health Administration (VA) revealed complementary and integrative health approaches can result in better patient health and satisfaction. The integrated services also were provided without difficulty at many VA sites. The integration included nonpharmacological options to address patients’ pain, anxiety, depression, and well-being.4

The authors of another study focused on the Mental and Behavioral Health Capacity Project, collecting data on the integration of mental health into undersourced primary health clinics in four states affected by natural disasters. Investigators found long-term outcomes of better informed and connected communities and greater capacity and sustainability for quality healthcare.5

A three-state study of Midwesterners with diabetes and depression revealed significant improvements in glycemic management and symptoms of depression among people who received a 12-week exercise intervention or a 12-week intervention that combined exercise with cognitive behavioral therapy (CBT).6

“That demonstrated to us there are multiple ways to improve depression,” says Mary de Groot, PhD, associate professor of medicine and acting director of the diabetes translational research center at Indiana University School of Medicine. She also is immediate past president for healthcare and education for the ADA.

For example, researchers found adults with type 2 diabetes benefited at three months postintervention assessment from exercise and/or therapy. Researchers found significant improvements in patients’ major depressive disorder (MDD) with three interventions: exercise, CBT, and a combination of exercise and CBT. Also, the combined exercise and CBT resulted in blood glucose (HbA1c) level improvements at three months postintervention.7

The researchers examined the cost-effectiveness of the exercise and CBT interventions, finding a savings of $313 per patient, representing a good value when compared with usual care. The interventions took place for three months in community settings and involved providers from healthcare systems and practice settings.7

“When we looked at the long-term effect and long-term outcomes, measured at 12 months postintervention, we observed that people in the exercise group not only had short-term improvement, but their improvement in HbA1c persisted even a year after the formal intervention was complete,” de Groot says. “What’s interesting is that not everyone maintained their same level of exercise a year later, but having this period of exercise — even for as little as three months — seemed to have a lasting improvement in A1c for up to a year later.”

Those findings had implications for cost-effectiveness as well. “If you can get people access to exercise and help them do it in a way that’s safe for them medically and physically, we can achieve significant health savings to health systems,” de Groot says. “Whether exercise was combined with CBT or on its own, they showed improvements that were pretty similar. This was consistent with what we would expect.”

The ADA’s position statement on psychosocial care for people with diabetes, which de Groot co-authored, states psychosocial care should be integrated with collaborative, patient-centered medical care. It also asks that providers consider an assessment of symptoms of diabetes distress, depression, anxiety, and other mental health issues at the initial visit and at periodic intervals.8

“With the recent diabetes guidelines, we’re talking more seriously about incorporating psychosocial care for people with diabetes,” Laiteerapong says.

People with diabetes are two to three times more likely to be diagnosed with depression than people without diabetes, and at least half live with undiagnosed and untreated depression, according to the Centers for Disease Control and Prevention.9

Anxiety also is more prevalent among people with diabetes. Overwhelming feelings of worry, frustration, and discouragement can lead to diabetes distress, which can affect up to half of people with diabetes within any 18-month period.9

The first step to solving this problem is to improve depression screening and diagnosis. “Think about it as a process. You can’t treat, support, or do anything if you don’t know what to deal with, so it’s really important to do a good assessment,” says Mark Peyrot, PhD, professor emeritus of sociology at Loyola University Maryland.

Providers need to ask about patients’ experiences and feelings during initial and subsequent visits. If a case manager or another provider asks if the patient with diabetes feels sad most days, and the patient says yes, then the patient needs further assessment for depression, Peyrot says. (See story on assessing and helping patients with diabetes and depression in this issue.)

In the FQHC study, researchers examined if better behavioral health integration could improve diabetes control. They surveyed people at FQHCs, asking about their behavioral health integration, the types of behavioral health services they provided, and whether they worked collaboratively with primary care clinics.1 “We asked how things were going and what was the status of integration of depression and diabetes care,” Laiteerapong says. “We linked survey data results to health center-level diabetes control.”

The researchers found the FQHCs that used better or more integration of diabetes and depression care saw fewer patients with uncontrolled diabetes, Laiteerapong says.

“We also found that onsite diabetes health self-management education was associated with fewer patients with uncontrolled diabetes,” she adds. “That’s a finding you’d expect; you hope that having education was associated with better diabetes control.”

But the success of integrated diabetes and depression care is an important finding. “There’s something about not having just behavioral healthcare, but having behavioral healthcare and diabetes integrated, which is associated with better control of diabetes,” Laiteerapong says.

The study revealed 65% of health centers used both diabetes and behavioral health patient tracking systems, and 43% had one person managing both tracking systems.1

“Someone might think it’s uncommon to have someone manage both mental health and diabetes care, but at these federally qualified health centers, which generally are under-resourced, 43% had the same person,” Laiteerapong says.

Other services associated with better glycemic control included a tracking system for clinical diabetes, clinical decision support tools, and self-management education. More than 80% of the FQHCs used a diabetes screening protocol and a patient tracking system. Tracking systems included registries and case managers following up with patients.1

Integrated services may include one case manager helping patients with both their medical issues and their mental health issues. “Case managers can reach out to people who have uncontrolled diabetes and who haven’t come into the clinic for a while to make sure they are using their new medicine,” Laiteerapong explains. “This is an example of higher-level case management.”

The researchers found primary care providers were satisfied with diabetes care resources and interventions. They agreed their diabetes screening protocol was accurate, efficient, and followed consistently. Behavioral health services at the FQHCs included counseling, same-day appointments as primary care appointments, depression screening, warm handoffs during clinic visits, and anxiety screening.1

The study results reinforce the concept that physical and mental healthcare should not be segregated to different facilities. “To have good physical health, you need good mental health,” Laiteerapong says. “These problems are intertwined.”

It creates an unnecessary barrier when healthcare organizations outsource their mental health care to other providers. It can prevent the health system from achieving better quality care for patients.

The other takeaway is that employing case managers in the role of assisting patients with their chronic illnesses and mental health issues is helpful for value-based care. “The old-fashioned lesson and concept is that physical and mental healthcare should not be segregated to different healthcare providers,” Laiteerapong adds.

REFERENCES

  1. Laiteerapong N, Staab EM, Wan W, et al. Integration of diabetes and depression care is associated with glucose control in Midwestern federally qualified health centers. J Gen Intern Med 2021;36:978-984.
  2. Sara G, Chen W, Large M, et al. Potentially preventable hospitalisations for physical health conditions in community mental health service users: A population-wide linkage study. Epidemiol Psychiatr Sci 2021;30:e22.
  3. de Groot M, Shubrook J, Schwartz F, et al. Program ACTIVE II: Design and methods for a multi-center community-based depression treatment for rural and urban adults with type 2 diabetes. Diabetes Res Ther 2015;1:10.16966/2380-5544.108.
  4. Farmer MM, McGowan M, Yuan AH, et al. Complementary and integrative health approaches offered in the Veterans Health Administration: Results of a national organizational survey. J Altern Complement Med 2021;27:S124-S130.
  5. Hansel T, Osofsky H, Langhinrichsen-Rohling J, et al. Lessons learned from a quad-state postdisaster project: Developing accessible and sustainable integrated mental and physical health care services. J Ambul Care Manag 2018;41:323-332.
  6. de Groot M, Shubrook JH, Hornsby Jr. WG, et al. Program ACTIVE II: Outcomes from a randomized, multistate community-based depression treatment for rural and urban adults with type 2 diabetes. Diabetes Care 2019;42:1185-1193.
  7. de Groot M, Doyle T, Averyt J. Program ACTIVE: Cognitive behavioral therapy to treat depression in adults with type 2 diabetes in rural Appalachia. J Cogn Psychother 2017;31:158-170.
  8. Young-Hyman D, de Groot M, Hill-Briggs F, et al. Psychosocial care for people with diabetes: A position statement of the American Diabetes Association. Diabetes Care 2016;39:2126-2140.
  9. Centers for Disease Control and Prevention. Diabetes and mental health. Last reviewed Aug. 6, 2018.